title: 30-day hospital readmission of older adults using care transitions after hospitalization: a pilot prospective cohort study.
abstract: OBJECTIVE
  Patients leaving the hospital are at increased risk of functional decline and hospital readmission. The Employee and Community Health service at Mayo Clinic in Rochester developed a care transition program (CTP) to provide home-based care services for medically complex patients. The study objective was to determine the relationship between CTP use, 30-day hospital readmission, and Emergency Room (ER) visits for adults over 60 years with high Elder Risk Assessment scores.
  
  
  METHODS
  This was a pilot prospective cohort study that included 20 patients that used the CTP and 20 patients discharged from the hospital without using the CTP. The medically complex study patients were drawn from the department of Employee and Community Health population between October 14, 2011 and September 27, 2012. The primary outcomes were 30-day hospital readmission or ER visit after discharge from the hospital. The secondary outcomes were within-group changes in grip strength, gait speed, and quality of life (QOL). Patients underwent two study visits, one at baseline and one at 30 days postbaseline. The primary analysis included time-to-event from baseline to rehospitalization or ER visit. Paired t-tests were used for secondary outcomes, with continuous scores.
  
  
  RESULTS
  Of the 40 patients enrolled, 36 completed all study visits. The 30-day hospital readmission rates for usual care patients were 10.5% compared with no readmissions for CTP patients. There were 31.6% ER visits in the UC group and 11.8% in the CTP group (P = 0.37). The secondary analysis showed some improvement in physical QOL scores (pre: 32.7; post: 39.4) for the CTP participants (P < 0.01) and no differences in gait speed or grip strength.
  
  
  CONCLUSIONS
  Based on this pilot study of care transition, we found nonsignificant lower hospital and ER utilization rates and improved physical QOL scores for patients in the CTP group. However, the data leads us to recommend future studies with larger sample sizes (N = 250).
authors.affiliation: Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA. takahashi.paul@mayo.edu
authors.forename: Paul Y
authors.initials: PY
authors.lastname: Takahashi
authors.forename: Lindsey R
authors.initials: LR
authors.lastname: Haas
authors.forename: Stephanie M
authors.initials: SM
authors.lastname: Quigg
authors.forename: Ivana T
authors.initials: IT
authors.lastname: Croghan
authors.forename: James M
authors.initials: JM
authors.lastname: Naessens
authors.forename: Nilay D
authors.initials: ND
authors.lastname: Shah
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Hanson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D003266:Continuity of Patient Care / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D005684:Gait / Q000502:physiology; D015577:Geriatric Assessment; D018737:Hand Strength / Q000502:physiology; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data*; D010865:Pilot Projects; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011788:Quality of Life; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome
keywords: case management; cohort study; frailty; geriatrics